Yesterday the New York Times asked me to participate in a "Room for Debate" forum on Medicare reform. Here’s the topic: "The Obama administration will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive. What’s the one thing Medicare should stop paying for? Please be specific."

See the full Forum, and reader’s comments here. The New York Times also ran a news story that questioned Medicare’s plans that you can access here.

Below, my contribution to “Room for Debate.”

Note: The Times headlined my piece “Don’t Let Oncologists Make All of the Decisions” which might suggest that I’m “blaming oncologists.” My original headline was the one I use below. My argument is that the burden is on the hospital: it’s up to the hospital to ensure that patients know that palliative care exists, and that a palliative care consult doesn’t mean that they are dying or that they should give up treatment. Palliative care consults are appropriate for any seriously ill patient who wants to know more about his odds and the risks and benefits of various procedures.

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The Wall Street Journal calls it the “Medicaid Fat Fee,” Time magazine refers to “Arizona’s Flab Tax”  while Arizona’s top health officials say a proposed penalty that would be levied on certain Medicaid recipients “is a way to reward good behavior”—a stick without the carrot approach.

At issue is the latest plan to help Arizona make up for its $1.15 billion budget shortfall and planned 28% cut to the state’s Medicaid program. The idea is to require certain childless adults—those who are obese and fail to follow a doctor-ordered weight-loss plan; those who are chronically ill with a condition like diabetes and don’t adhere to recommended treatment; and smokers—to pay a $50 surcharge.

If instituted, the plan is projected to add about $500 million to fill the budget deficit. It would also signal the first attempt ever to penalize Medicaid recipients for what the state deems “unhealthy behaviors” that drive up health care costs. “If you want to smoke, go for it,” said Monica Coury, spokeswoman for Arizona's Medicaid program. “But understand you're going to have to contribute something for the cost of the care of your smoking.”

Despite support from Gov. Jan Brewer and the GOP-heavy Arizona state legislature, the proposed “fat tax” has its detractors, especially among advocates for the poor. In an interview on Southern California Public Radio (SCPR), Arthur Caplan, Director of the Center for Bioethics at the University of Pennsylvania said of the plan “I don’t think it’s fair, I think it’s a bad idea.” Caplan says singling out the “poorest of the poor,” (in Arizona we’re talking about a family of two earning under $15,000/yr) is “regressive, short-sighted and cruel… It’s just easy to pick on the poor who do stigmatized things.”

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Over at “Ohio Surgery” Buckeye Surgeon is not at all happy with the commencement speech that fellow-surgeon Atul Gawande recently delivered to Harvard Medical School’s graduating class. Today, Buckeye (a.k.a Jeffrey Parks, a general surgeon on the East Side of Cleveland, Ohio), summed up what he called  Gawande’s “essential message”:

“Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms. . . Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) . . . All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew.” 

No surprise, Gawande, who is a regular contributor to The New Yorker, makes his case in somewhat more eloquent terms: “The distance medicine has travelled in the [last] couple of generations is almost unfathomable,” he writes, comparing that span to the “vast quantum leap” his father made when he traveled “from his rural farming village of five thousand people [in India] to Nagpur, a city of millions where he was admitted to medical school, three hundred kilometers away. Both communities were impoverished. But the structure of life, the values, and the ideas were so different as to be unrecognizable. Visiting back home, he found that one generation couldn’t even grasp the other’s challenges. Here is where we seem to find ourselves, as well.” 

Medical culture has been roiled by change, leaving some doctors who remain attached to the past dismayed. This was inevitable, Gawande says.  In the past, physicians had only a handful of remedies. “Now we have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. . .

“We in medicine, however, have been slow to grasp . . .  how the volume of discovery has changed our work and responsibilities . . .” he added, “The rapid growth in medicine’s capacities is not just a difference in degree but a difference in kind . . . the reality is that medicine’s complexity has exceeded our individual capabilities as doctors.”

He told the graduates that In earlier decades, “The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. . .  We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”             '

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In the post below, “Can Empathy Be Taught?” Dr.  Chris Johnson reflects on how and why, so many medical students seem to lose that compassion for others that is “innate in all of us,” and causes many students to choose the profession in the first place. Johnson writes: “We need to prevent medical training from driving [compassion] into the background, belittling it, or even snuffing it out.”

For nearly thirty years Johnson has been practicing medicine in an area that makes great demands on both the heart and the mind—pediatric critical care. It is a field that, in the words of 19th century medical ethicist Thomas Percival requires that the physician “unite” great “tenderness with steadiness.” Johnson is a blogger and the author of  How Your Child Heals, How to Talk to Your Child’s Doctor, and Your Critically Ill Child.

Throughout most of his career, he has taught medical students, residents, and fellows. “I also served on a medical school admissions committee for some years,” he notes “and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system got hold of them.”

Before reading Johnson’s post, you should know what inspired it.

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By Chris Johnson, M.D. 

We want competent physicians, but we also want compassionate ones. How do we get them? Is it nature or is it nurture? Is it more important to search out more compassionate students, or should we instill compassion somehow in the ones we start along the training pipeline? I think the answer lies in nurturing what nature has already put there.

Throughout most of my career in pediatric critical care I have taught medical students, residents, and fellows. So I have seen young physicians as they made their way as best they could through the long training process.

After reading Doctor Treadway’s essay, I think my overall perspective on the question is similar to hers – the main principle to keep before us is not so much that we need to figure out a way to teach compassion, but rather to devise ways such that the training process does not reduce, or even extinguish, the innate compassion all humans have toward one another. Unfortunately, our current way of doing things does not do a very good job at that task. We are hobbled by our success. Some historical background is helpful, I think, to explain what I mean.

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When we dole out blame for rising health care costs the familiar suspects are hospitals, insurers, and profit-hungry drug and device makers. High-priced specialists usually rate a mention as well. But what about primary care physicians? It turns out that through excessive testing, improper prescribing and other types of unnecessary care these “gate-keepers” also contribute to spiraling health care spending. And worse, this excess treatment not only doesn’t help patients, it can actually harm them.

This week the National Physician’s Alliance released the "Top 5" ways primary care physicians like internists, family practitioners and pediatricians can reduce health care costs while also improving the quality of care for their patients. Their recommendations are surprisingly simple and in most cases advise against the overuse of certain tests and therapies. They are recommendations that should be—but often aren’t—considered the standard of care; for example, not ordering EKG’s or cardiac screening for low-risk patients; not prescribing antibiotics for a child’s sore throat until a strep test confirms infection, and not performing x-rays or CT scans on patients who have experienced fewer than six weeks of lower back pain unless “red flags” are present.

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Trustees’ Report Much Less Gloomy than Advertised        
      
Summary: Below, Part 2 of the May 13  post headlined “Medicare Trustees Report that Reform Legislation Cuts Medicare Costs by 25 Percent.”

Conservatives continue to use the annual report recently released by Medicare’s Trustees as evidence that Medicare needs what one conservative pundit calls a “sweeping overhaul.”  In theory, House Budget Chairman Paul Ryan’s plan to privatize Medicare is dead, but somehow, it’s still in the news. Yesterday Newt Gingrich announced that he’s with Ryan, and today Senator John Kerry is calling a press conference to denounce Ryan’s voucher plan.

What has been lost in the debate is the fact that the Trustee’s report is not nearly as gloomy as advertised. Anyone who reads the entire report will find a major disconnect between the headlines and what the trustees actually say. In this post, I quote the Trustees as they express their optimism that Medicare’s challenges can be solved by “building on” the Affordable Care Act (ACA). They also recognize that the ACA calls for structural changes “in how health care is financed and delivered” that could yield substantial savings. Meanwhile, Medicare Actuary Richard Foster has issued a dissenting opinion to the Trustees’ report, arguing that their predictions are based upon unrealistic spending cuts. Foster doesn’t believe that hospitals can become more efficient. In this post I explain that a fair number of hospitals already have proven him wrong, and research by the non-partisan  Medicare Payment Advisory Commission (MedPac) reveals that there is plenty of hazardous waste to be squeezed out of our hospital system.(I call the excess “hazardous” because it includes so many preventable medical errors.)  Finally, at the end of the post, I itemize exactly how and where the ACA saves money and raises new revenues, which, according to the Congressional Budget Office, will total $950 billion over the course of the decade.

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For young women just starting out in a new city and in need of primary reproductive care, Planned Parenthood is a trusted and necessary provider. The same is true for wary teenagers and women of limited financial means all over America who want to be responsible about preventing pregnancy and sexually transmitted diseases but face limited options for care. For mothers, single women, poor women, middle class women and teenagers alike, the 865 Planned Parenthood clinics around the country provide a safe, affordable and easily accessible haven for essential care, including access to contraceptives, preventive services like Pap screening for cervical cancer and testing for sexually transmitted diseases. And although many of these clinics do offer safe abortions; when you include both the surgical and non-surgical kind, abortion makes up just 3 percent of all the services proffered each year by Planned Parenthood.

That 3 percent was enough to convince Governor Mitch Daniels of Indiana (a former hopeful in the upcoming Republican presidential race) to sign into law this month the first bill to eliminate all federal and state Medicaid funding for 28 Planned Parenthood clinics that provide care to 9,300 women covered by Medicaid in in his state. Of course it’s true that the Hyde amendment already prohibits federal support for abortion in Indiana (as it does in all states). And Indiana is one of 33 states that also prohibits state Medicaid funding for the procedure except in the case of rape, incest or life endangerment. So by passing—and already enforcing—a law that denies coverage to poor women using Planned Parenthood, Indiana is not really battling abortion, but instead singling out one of the top providers of women’s health care and effectively blocking access to preventive reproductive care and family planning services.

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Today, S&P released data tracking the growth of health care costs which showed that over the year ending March 2011, Medicare spending rose at an annual rate of 2.78%—the lowest rate posted for the Medicare Index in its six-year history. (Hat-tip to Kent Bottles for calling attention to this report on Twitter. This news is, as Bottles says, “very important”, not to mention timely, given the deficit debate in Washington.)

By contrast, over the same 12 months, health care costs covered by commercial insurers rose by 7.57%.  Still, as the chart below shows, even these costs (tracked by the “commercial index”) have been falling, down from a peak inflation rate of nearly 10 percent in the 12 months ending in July 2010 to 7.5% in the 12 months ending March 2011.

Why is health care inflation decelerating?  In the commercial sector, the recession no doubt plays a major role.  Insured patients often have high deductibles that must be paid before they receive care. As a result, hospitals report that patients are putting off elective surgery.  Thus, commercial insurers are paying out a lower share of premiums. (See for example, Cigna’s most recent financial report which shows patients’ “relatively moderate use of medical services”.)

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At the core of health reform is an increased emphasis on evidence-based medicine; a movement toward reimbursement policies and quality ratings that encourage doctors and hospitals to use the most effective and patient-appropriate treatments, backed by clinical data and scientific studies. But when it comes to interventional cardiology—using devices like balloon angioplasty and stents to open blocked arteries—it seems that evidence is still taking a back seat to deeply ingrained practice patterns.

Case in point: Even though many well-designed clinical studies conclude that drug therapy can reduce the risk of heart attack and death in people with stable coronary artery disease just as well as more expensive invasive procedures, many cardiologists continue to use interventions like propping open blocked arteries with costly stents instead of first trying medication. Besides exposing their patients to unneeded risk, just the inappropriate use of so-called “drug-eluting” stents alone increases Medicare expenditures by $1.57 billion each year.

“We’re still not seeing practice trends that are consistent with people following the evidence,” Peter W. Groeneveld, assistant professor of medicine at the University of Pennsylvania School of Medicine tells me. In fact, he continues, it seems that cardiologists are actually “resolutely ignoring the evidence” in favor of performing interventions that they seem to believe are better. Or, as the Los Angeles Times put it recently; “You can lead a cardiologist to water but, apparently, you cannot make him drink.” 

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